In Custody Death*

states: "The request by the inmate/decedent to be transferred to the hospital was written in the psychiatric evaluation conducted at 9:30 a.m. on August 4 and repeated in the nurse's progress notes at 5:00 p.m." CFMG does not dispute Ms. Stepelton informed the psychiatric nurse at 9:30 a.m. that she felt sick and thought she needed an IV at the hospital. However, there was nothing about the patient's condition at any time during her incarceration which indicated she required hospitalization or any higher level of care than what she was receiving by CFMG. The patient was undergoing alcohol withdrawal after having admitted to consuming a pint-and-a-half of vodka before her incarceration. Her complaints of vomiting and diarrhea were to be expected and she was prescribed and given medications to control these conditions. Her physical examinations and complaints did not indicate she had any underlying conditions such as acute pancreatitis or sepsis which required transfer to the hospital. In fact, her vital signs were essentially stable given the fact she was undergoing alcohol withdrawal. She was properly treated for alcohol withdrawal syndrome, including receiving appropriate hydration, medications, vitamins and supplements. В.

states: "The sheriff's inmate monitoring log, the psychiatric evaluation and the nurse's progress notes do not match. The psychiatric evaluation and the nurse's progress notes each record the inmate's/decedent's request to transfer to the hospital. The sheriff's log did not contain this request. There were discrepancies in the nurse's progress notes and the psychiatric evaluation. The main discrepancy showed time differences, hours apart, documenting the request for hospital transfer." The Sheriff's Inmate Monitoring Log is not designed to record any medical or mental health conditions regarding the patient. Those notations are specifically reserved for the patient's confidential medical records. In fact, it is inappropriate for custody to document the contents of The Honorable Brian J. Back September 25, 2013 any discussions or partial discussions between medical and/or psychiatric staff and the inmates on the Sheriff's Inmate Monitoring Log. CFMG would not expect the Sheriff to include the patient's request to be transferred to the hospital on the Sheriff's Inmate Monitoring Log. These requests are clearly documented in the patient's medical chart and it is a medical judgment regarding whether or not the patient should be transferred to the hospital. CFMG staff does review the Sheriff's Inmate Monitoring Log when they evaluate the patient. The CFMG nurse's progress note at 5:00 p.m. and the psychiatric evaluation which is recorded at 9:30 a.m. does not contain any discrepancies. These notes record what was transpiring with the patient at the time of the respective evaluations. The patient did not request to be transferred to the hospital when she was evaluated by the nurse at 5:00 p.m. Instead, the nurse was simply reflecting her review of the earlier notation in the psychiatric evaluation at 9:30 a.m., which indicated the patient thought she needed to be transferred to the hospital. C.

states: "Neither the sheriff's monitoring log nor the nurse's progress notes record the psychiatric evaluation that occurred at 9:30 a.m. on August 4, 2012." The Sheriff's Monitoring Log is not designed to include information regarding a patient's psychiatric evaluation. This would be a violation of HIPAA and the patient's right to confidentiality of medical information. The nurse's progress notes do not record the psychiatric evaluation that occurred at 9:30 a.m. because that psychiatric evaluation is fully reflected in the patient's medical chart and there is no need to record it in the nurse's progress notes because the psychiatric evaluation is fully reflected in the patient's mental health portion of the medical record.. D.

states: "The inmate/decedent was determined, during the intake process, to be okay to book and be placed in the medical/special housing unit." CFMG agrees with this finding. The patient underwent a thorough intake screening which indicated she did not have any underlying medical condition which required that she be transferred to the hospital or a higher level of care. In fact, Ms. Stepelton was cooperative, alert, and oriented to person, time and place. She did not complain of any chest pain, shortness of breath, headache, vertigo, blurred vision, or recent head injury. She maintained good eye contact with the nurse and her thought process was organized. She was not angry, hostile, labile or manic. She did not complain of auditory hallucinations, visual hallucinations, grandiose delusions or paranoid delusions. . . The Honorable Brian J. Back September 25, 2013 Ms. Stepelton did report that she had a history of alcohol abuse and had consumed 1 1/2 pints of vodka on August 3, 2012. She was appropriately placed on an alcohol withdrawal syndrome protocol based on this history and treated in compliance with the protocol. E.

states: "At the time she died, on August 4, 2012, a contributing factor in the inmate/decedent's death was a lack of timely medical attention while in custody." CFMG wholly disagrees with this finding. The autopsy report indicates the patient had a natural cause of death. The cause of death is specifically listed as probable bacterial sepsis due to complications of acute suppurative pancreatitis with pancreatic abscess due to complications of chronic pancreatitis due to complications of chronic ethanolism. During her incarceration, CFMG staff recognized the patient was undergoing alcohol withdrawal and she was properly placed on and treated pursuant to a standardized alcohol withdrawal syndrome protocol. She was appropriately hydrated and given standard medications, vitamins and supplements to treat her alcohol withdrawal. The patient never complained of any signs or symptoms which indicated she had an underlying acute pancreatitis and/or sepsis. She was able to drink fluids and eat the meals which were served to her. In addition, at no time did she complain of any abdominal or gastrointestinal symptoms which would be indicative she had an underlying pancreatitis or septic condition. In fact, when Dr. Adler performed his abdominal examination of the patient, she did not complain of any rebound tenderness or pain. In addition, when she was evaluated by Armando Gomez, R.N., she specifically reported she did not have any complaints of nausea, vomiting or diarrhea. Unfortunately, Ms. Stepelton died of natural causes which were directly related to her chronic alcohol abuse. Her death had nothing to do with the alleged lack of treatment and care she received by CFMG. CFMG has had this file reviewed by Dr. Lanyard Dial. He has personally reviewed the relevant medical records in this case and believes CFMG's treatment of the patient had at all times complied with standards of care and did not contribute to her death. Dr. Lanyard Dial comments on the Grand Jury's Finding FI-06 as follows: This finding is stated as, "At the time she died, on August 4, 2012, a contributing factor in the inmate's/decedent's death was a lack of timely medical care while in custody." This finding references the FACTS as FA-02, 05-07, and 11. These FACTS note the inmate's request to go to the hospital, her alcohol withdrawal monitoring, the lack of monitoring logs not mentioning alcohol withdrawal symptoms, not mentioning illness, and no record of requests for assistance made by the inmate and others. It is my opinion that none of these show the lack of timely medical attention while in custody occurred, and that such attention was a The Honorable Brian J. Back September 25, 2013 contributing factor in her death. It is my opinion that her medical care was appropriate given her signs and symptoms. Her condition was not diagnosable prior to her death given the facts I was given to review. I do not agree with the conclusion of the Grand Jury's interpretation of the medical facts. (Please see Exhibit B.) The Grand Jury Report does not include the declaration of any expert which supports their unfounded conclusion that: "A contributing factor in the inmate's/decedent's death was a lack of timely medical attention while in custody." This is an unsubstantiated conclusion without any expert support and reflects a significant lack of understanding regarding the medical treatment and care the patient actually received. F.

states: "Lack of documentation and its discrepancies led to the inability of staff to adequately assess her condition. The inmate/decedent's medical chart was incomplete." CFMG wholly disagrees with this finding and fails to understand how the Grand Jury comes to this unfounded and unsubstantiated conclusion. The report fails to identify what is specifically lacking in the documentation which was performed by the CFMG physician and nurses. The report fails to identify what is "incomplete" about the patient's medical chart. In addition, there are no "discrepancies" in the patient's medical chart nor was there an inability of staff to adequately assess Ms. Stepelton's condition. There was clear communication between the nurses and physicians in this case which led to the provision of appropriate medical care and treatment for the patient's condition. Dr. Jung and Dr. Adler issued appropriate orders and they were all carried out in a timely and appropriate fashion by the CFMG nursing staff. The nursing staff performed proper evaluations of Ms. Stepelton, including obtaining her vital signs on each occasion they saw her. The nurses had the opportunity to personally interact with Ms. Stepelton and determine whether she had any physical or medical complaints which required further evaluation and treatment. The nursing staff properly documented changes in the patient's condition which required that she be placed on the Level I alcohol withdrawal syndrome protocol. There is nothing the CFMG healthcare providers did, or failed to do, which fell beneath standards of practice and, according to Dr. Lanyard Dial, the patient's death was not caused by any deviations in the standard of care by CFMG personnel. G.

states: "There was a debriefing by the VCSD after the death, but no formal document was written or recorded into the inmate's/decedent's record." CFMG does not include the report of any death investigations or reviews in a patient's medical chart. . The Honorable Brian J. Back September 25, 2013 CFMG responds to the recommendations of the Grand Jury Report as follows: CFMG'S RESPONSE TO THE GRAND JURY'S RECOMMENDATIONS. A.